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Keep up to date with the latest news, research and activity in patient safety.

Mother and baby units: 'It's our job to keep them safe'

"Women may be suicidal or want to die. They may have thoughts about harming their baby. It's our job to keep them safe until they can keep themselves safe," says Debbie Sells.
She manages a mother-and-baby unit in Nottingham which supports a small group of new mothers and pregnant women with serious psychological problems.
It's one of 19 units across England which each year treat about 800 women with perinatal mental health problems like psychosis and severe depression.
Clinicians say it is important to keep mothers and babies together to protect their relationship and the infant's development.
Some clinicians fear there may soon be an increased demand for their services due to extra pressures pregnant women are facing during the pandemic.
"We are hearing stories of women delivering on their own and not having the support of their partner, says Debbie.
"A traumatic birth can lead on to other things. Now not only are women becoming seriously unwell with a baby, but it's happening within a pandemic"
NHS England says while it is understandable some women and their families may have felt uneasy about seeking help in the early stages of the outbreak, it is vital they ask for support if it is needed.
Read full story
Source: BBC News, 26 October 2020
Sam

Covid: Antibodies 'fall rapidly after infection'

Levels of protective antibodies in people wane "quite rapidly" after coronavirus infection, say researchers.
Antibodies are a key part of our immune defences and stop the virus from getting inside the body's cells. The Imperial College London team found the number of people testing positive for antibodies has fallen by 26% between June and September.
They say immunity appears to be fading and there is a risk of catching the virus multiple times.
More than 350,000 people in England have taken an antibody test as part of the REACT-2 study so far. 
In the first round of testing, at the end of June and the beginning of July, about 60 in 1,000 people had detectable antibodies. But in the latest set of tests, in September, only 44 per 1,000 people were positive.
"Immunity is waning quite rapidly, we're only three months after our first [round of tests] and we're already showing a 26% decline in antibodies," said Prof Helen Ward, one of the researchers.
The fall was greater in those over 65, compared with younger age groups, and in those without symptoms compared with those with full-blown COVID-19. The number of healthcare workers with antibodies remained relatively high, which the researchers suggest may be due to regular exposure to the virus.
There have been very few confirmed cases of people getting Covid twice. However, the researchers warn this may be due to immunity only just starting to fade since the peak infection rates of March and April.
The hope is the second infection will be milder than the first, even if immunity does decline, as the body should have an "immune memory" of the first encounter and know how to fight back.
The researchers say their findings do not scupper hopes of a vaccine, which may prove more effective than a real infection.
One of the researchers, Prof Graham Cooke, said: "The big picture is after the first wave, the great majority of the country didn't have evidence of protective immunity. The need for a vaccine is still very large, the data doesn't change that."
Read full story
Source: BBC News, 27 October 2020
Sam

Trust warned by CQC sees fourth inpatient death following ‘humongous’ problems

A fourth suspected suicide has occurred at a mental health trust which was recently warned by the Care Quality Commission after three other similar inpatient deaths in quick succession, HSJ can reveal.
All four deaths at Devon Partnership Trust had common themes, including the use of ligatures, and occurred amid a year-long delay to the trust’s plan to reduce ligature risks.
Figures obtained by HSJ under freedom of information laws also reveal the trust took nearly a year to investigate the first two deaths. The target is 90 days.
The trust told HSJ it had faced “humongous” problems addressing ligature risks and had been too “patient” with another trust which was helping to investigate the deaths.
Read full story (paywallled)
Source HSJ, 27 October 2020
Sam

Patients discharged from hospitals without Covid test results

Almost half of hospital patients have been discharged without receiving the results of their coronavirus test – including some patients who were sent to care homes, new research from Healthwatch and British Cross has revealed.
Independent national patient body Healthwatch England said it had learned many patients were discharged from hospitals between March and August this year without proper assessments with many vulnerable people sent home without medication, equipment or the care they needed.
At the start of the pandemic thousands of patients were discharged to care homes as NHS England instructed hospitals to free up 15,000 beds ahead of the first wave of coronavirus.
Approximately 25,000 patients were sent to care homes with some not tested, sparking fears this helped seed care homes with the virus. There have been around 16,000 care home deaths linked to COVID-19.
According to a survey of almost 600 discharged patients and interviews with 60 NHS staff, Healthwatch England said it had found serious flaws with the way hospitals had followed NHS England’s instructions.
Read full story
Source: The Independent, 24 October 2020
Sam

Fears of 'two-tier' system as NHS waiting lists prompt more people to go private

Concerns are growing that long NHS waiting times caused by the coronavirus crisis are exacerbating pre-existing health inequalities and creating a “two-tier” system, as more people turn to the private sector for quicker treatment.
As leading doctors warn mass cancellations of NHS operations in England are inevitable this winter after waiting times reached the highest levels on record this summer, data shows a rise in the number of people self-funding treatment or investing in private health insurance.
“COVID-19 has not impacted everyone equally, and there is clearly a risk that the backlog in routine hospital treatment is going to add to those inequalities if some people are able to get treatment faster because they’re able to pay,” said Tim Gardner, from the Health Foundation thinktank.
As the NHS heads into winter and a growing second wave of the virus, experts stressed the need to help those affected by the backlog now.
“There is a need to prioritise the most urgent cases, but simply because someone’s case isn’t urgent doesn’t mean it’s not important. It doesn’t mean that people aren’t waiting in pain and discomfort, or waiting anxiously for a diagnosis,” said Gardner.
“We think it’s incumbent on the health service to make the best possible use of the capacity it’s got. But also it needs to make sure it’s supporting people while they’re waiting. We just can’t have people left in limbo.”
Read full story
Source: The Guardian, 27 October 2020
Patient Safety Learning

After scandals like Winterbourne View, why is basic decency still remarkable?

In late July 2019, Sara Ryan tweeted asking families with autistic or learning disabled children to share their experience of “sparkling” actions by health and social care professionals. She was writing a book about how professionals could make a difference in the lives of children and their families.
"These tweets generated a visceral feeling in me, in part because of the simplicity of the actions captured. Why would you not ring someone after a particularly difficult appointment to check on them? Isn’t remembering what children like and engaging with their interests an obvious way to generate good relationships? Telling a parent their child has been a pleasure to support is commonplace, surely?"
Sara's own son, Connor, was left to drown in an NHS hospital bath while nearby staff finished an online Tesco order. "Certain people, children and adults, in our society are consistently and routinely positioned outside of 'being human', leading to an erasure of love, care and thought by social and healthcare professionals. They become disposable."
What has become clear to Sara is how much the treatment of people and their families remains on a failing loop, despite extensive research, legislative and policy change to make their lives better, and potentially transformative moments like the exposure of the Winterbourne View scandal. At the heart of this loop are loving families and a diverse range of allies, surrounded by a large cast of bystanders who, instead of fresh eyes, have vision clouded by ignorance and sometimes prejudice.
"To rehumanise society, we need more people with guts and integrity who are prepared to step up and call out poor practice, and to look afresh at how we could do things so much better with a focus on love and brilliance."
Read full story
Source: The Guardian, 27 October 2020
Sara Ryan's book: Love, learning disabilities and pockets of brilliance: How practitioners can make a difference to the lives of children, families and adults
Patient Safety Learning

Why most hospitals could save millions by improving patient safety

The first wave of COVID-19 may gave subsided in some areas of the United States, but in others it is growing and hospitals everywhere are continuing to face significant challenges.
The American Hospital Association recently estimated that hospitals will incur at least $323.1 billion in losses through the end of this year due to COVID-19. Key contributors include postponed and cancelled elective procedures, lower patient volumes across all departments, and higher costs for supplies and devices.
Other factors compound the financial challenges, including pressure for hospitals to implement new initiatives that foster a safer care environment for COVID-19 patients, non-COVID-19 patients, and healthcare providers. This pressure is mounting, as spikes in cases continue to appear in various regions, and as concerns grow about the flu season.
The good news is that improving patient, staff, and visitor safety can actually help hospitals recover from the financial losses they are experiencing due to the pandemic. For example, enhanced patient safety leads to:
Fewer costly events, such as hospital-acquired infections or conditions, acute kidney injuries, adverse drug events, readmissions, and return visits to the emergency department. Faster and more proactive identification of cost-saving opportunities, such as IV to PO conversions and more optimal management of high-cost drugs. Higher patient volumes due to a stronger quality and safety reputation.  Hospitals face significant financial challenges, but they must also act quickly to ensure patient, staff, and visitor safety. Luckily, improving margins and enhancing patient safety don’t need to be competing priorities. When hospitals implement effective safety improvement approaches, margin improvements naturally follow.
Read full story
Source: MedCity News, 25 October 2020
Sam

CCG lead condemns ‘heartbreaking’ visiting rule at local hospitals

A GP commissioning leader has publicly criticised hospital visiting rules at local hospitals, after hearing that a stroke patient was denied seeing family or friends for six weeks.
Philip Stevens, a locality chair at Northamptonshire Clinical Commissioning Group (CCG), described the situation reported to him by one of his patients as “heartbreaking”, and has challenged visiting policies at Northampton General Hospital and Kettering General Hospital trusts. 
During a CCG governing body meeting, Dr Stevens called for explanation from the county’s director of public health, Lucy Wightman, who said trusts could choose their own rules.
Dr Stevens, who is also a GP at Brackley Medical Centre, argued that visitors were permitted in neighbouring counties, where he claimed there were similar covid case rates to Northamptonshire, which remains in tier 1 restrictions under the government’s framework.
He said: “I’ve been dealing this week with a family who, the wife’s husband, has been in Northampton General for six weeks now and has had no visitors at all during that time. He’s had a profound stroke and when he comes home he’ll need considerable community support which ordinarily the family would have been trained in but discharge is planned without any of that training.”
Mr Stevens said in an “adjacent county” hospital policy was that each patient would have ”one hour, one visitor each day” with 30-minutes in between visiting slots. While not named, trusts in neighbouring Cambridge and Lincolnshire both have policies that permit pre-booked visitors.
He added: “When I heard this story it seemed heartbreaking to me for this woman and her husband and I just wonder whether that this is a situation we should be challenging, particularly since it appears that the public health advice in an adjacent county may be different to that which is being offered within Northamptonshire.”
Read full story (paywalled)
Source: HSJ, 27 October 2020
Sam

NPA asks pharmacies to report all patient safety incidents as number plunge in Q2 of 2020

The National Pharmacy Association (NPA) has asked community pharmacies to report all patient safety incidents despite growing work pressure due to a persisting virus pandemic.
Since March, there has been a significant decrease in the number of patient safety incidents being reported, the NPA said in its medication safety update for the second quarter of 2020.
Overall, there was a 44.5% decrease in the number of incidents reported during the second quarter of the year, compared to the first quarter of 2020.
There was a 40.6% decrease in the number of patient safety incidents when compared to the same quarter in 2019.
“This is a significant reduction in number of incidents being reported. This may be due to the increased workload and pressure on pharmacy teams due to COVID-19 pandemic, whereby pharmacy teams may not be prioritising reporting of patient safety incidents, or due to other, as yet unknown, reasons,” NPA said in its update.
NPA advises community pharmacists to ensure that they report the actual degree of harm caused to the patient and not the potential harm that could have happened.
The pharmacy body also suggested pharmacists should make sure that they complete a detailed outcome if an incident did lead to moderate or severe harm to the patient. This allows a thorough analysis to be undertaken by the NPA.
Community pharmacists are also advised to ensure the incident form is fully completed, is accurate and includes sufficient details to allow meaningful analysis of the incident.
Read full story
Source: Pharmacy Business, 27 October 2020
Sam

NHS hospital forced to postpone cancer operations as Covid spreads on wards

Cancer patients have had surgery cancelled because of coronavirus for the first time as pressure mounts on hospitals from the second wave, The Independent has learnt.
Nottingham University Hospitals Trust has confirmed it had to postpone the operations because of the number of patients needing intensive care beds.
While hospitals across the north of England have been forced to start cancelling routine operations in the last 10 days, maintaining cancer and emergency surgery had been a red line for bosses given the risk to patients from any delays.
Cancer Research UK said it was “extremely concerning” that some operations had been postponed and called for urgent action and investment to make sure treatments were not curtailed further.
In a statement to The Independent, Nottingham University Hospitals medical director Keith Girling said: “We’ve had to make the extremely difficult decision to postpone operations for four of our cancer/pre-cancer patients this week due to pressure on our intensive care units from both Covid-19 and non-covid related emergencies."
“We expect to treat one of the postponed patients next week, and we’re in contact with the others to arrange a new date, which will be imminent. This delay, however short, will be incredibly hard for the patients and their families, and I’m truly sorry for any distress this will have caused.
Read full story
Source: The Independent, 27 October 2020
Sam

Transformative learning programme to improve workplace wellbeing and cut business costs

Organisations across the UK and beyond are set to benefit from a unique NHS- academic partnership which sees a focus on staff safety and morale – and delivers significant cost savings.
Together Northumbria University and Mersey Care NHS Foundation Trust are pioneering professional development courses on Restorative Just Culture. This approach at the Liverpool-based Trust has seen reduced dismissals and suspensions, leading to substantial business savings, and has generated great interest across the health sector.
Starting in 2016 Mersey Care has worked to deliver a Restorative Just Culture. And despite increasing its workforce by 135%, the Trust has since seen an 85% reduction in disciplinary investigations and a 95% reduction in suspensions – helping them drive down costs significantly. During the same period, it has also seen improved staff engagement and safety culture scores as measured by the NHS national staff survey.
Mersey Care’s Executive Director of Workforce Amanda Oates says: “Mersey Care started on our journey towards a Restorative Just and Learning Culture after conversations with our staff about the barriers staff faced delivering the best care that they could possibly give."
“The feedback was overwhelmingly about the fear of blame if something didn't go as expected. This was preventing staff from telling us what wasn’t working. More importantly, it was preventing the opportunity for learning from those things to prevent them from happening again. As a Board, we had the conversation - are we looking at problems the wrong way?”
Read full story
Source: FE News, 27 October 2020
Sam

Coronavirus: Government throwing ‘lit match into a haystack’ by discharging Covid patients to care homes

The government has been warned it is throwing “a lit match into a haystack” by discharging Covid-positive patients to care homes, with politicians demanding that the safety of residents and staff is guaranteed under the new policy.
During the first wave of the pandemic, approximately 25,000 hospital patients were sent to care homes – many of whom were not tested – which helped spread the virus among residents. Around 16,000 care home deaths have been linked to COVID-19 since the start of the crisis.
The strategy was one of the government’s “biggest and most devastating mistakes” of the crisis, says Amnesty International, and questions have been raised over the decision to introduce a similar policy as the UK’s second wave intensifies.
As part of the 2020 adult social care winter plan, the government has called on local authorities and care providers to establish “stand-alone units” – so-called “hot homes” – that would be able to receive and treat Covid hospital patients while they recover from the disease.
There is also an expectation that, due to housing pressures and a shortage of suitable facilities, some patients may be discharged to “zoned accommodation” within a home, before being allowed to return to normal living settings once they test negative for the virus.
Councils have been told to start identifying and notifying the Care Quality Commission of appropriate accommodation, and to ensure high infection prevention standards are met.
Under the requirements outlined by the government, discharged patients “must have a reported Covid test result". However, The Independent revealed on Monday that these rules have not been followed in some cases, with a recent British Red Cross survey finding that 26 per cent of respondents had not been tested before being discharged to a care home.
There is also concern whether care homes possess enough adequate personal protective equipment to prevent outbreaks, with the CQC revealing last month that PPE was still not being worn in some sites.
Read full story
Source: The Independent, 27 0ctober 2020
Sam

Structural racism led to worse Covid impact on BAME groups

Minority ethnic people in UK were ‘overexposed, under protected, stigmatised and overlooked’, new review finds.
Structural racism led to the disproportionate impact of the coronavirus pandemic on black, Asian and minority ethnic (BAME) communities, a review by Doreen Lawrence has concluded.
The report, commissioned by Labour, contradicts the government’s adviser on ethnicity, Dr Raghib Ali, who last week dismissed claims that inequalities within government, health, employment and the education system help to explain why COVID-19 killed disproportionately more people from minority ethnic communities.
Lady Lawrence’s review found BAME people are over-represented in public-facing industries where they cannot work from home, are more likely to live in overcrowded housing and have been put at risk by the government’s alleged failure to facilitate Covid-secure workplaces.
She demanded that the government set out an urgent winter plan to tackle the disproportionate impact of Covid on BAME people and ensure comprehensive ethnicity data is collected across the NHS and social care. The report, entitled An Avoidable Crisis, also criticises politicians for demonising minorities, such as when Donald Trump used the phrase “the Chinese virus”.
The report, which is based on submissions and conversations over Zoom featuring “heart-wrenching stories” as well as quantitative data, issued the following 20 recommendations:
Set out an urgent plan for tackling the disproportionate impact of Covid on ethnic minorities Implement a national strategy to tackle health inequalities Suspend ‘no recourse to public funds’ during Covid Conduct a review of the impact of NRPF on public health and health inequalities Ensure Covid-19 cases from the workplace are properly recorded Strengthen Covid-19 risk assessments Improve access to PPE in all high-risk workplaces Give targeted support to people who are struggling to self-isolate Ensure protection and an end to discrimination for renters Raise the local housing allowance and address the root causes of homelessness Urgently conduct equality impact assessments on the government’s Covid support schemes Plan to prevent the stigmatisation of communities during Covid-19 Urgently legislate to tackle online harms Collect and publish better ethnicity data Implement a race equality strategy Ensure all policies and programmes help tackle structural inequality Introduce mandatory ethnicity pay gap reporting End the ‘hostile environment’ Reform the curriculum Take action to close the attainment gap Read full story 
Source: The Guardian, 28 October 2020
Clive Flashman

Hospital Covid ‘hotspots’ mapped out in a new HSIB report

Hospital hotspots for COVID-19 have been highlighted in a new report by safety investigators.
The report by the Healthcare Safety Investigation Branch (HSIB) makes a series of observations to help the health service reduce the spread of coronavirus in healthcare settings. Hospital hotspots for COVID-19 included the central nurses’ stations and areas where computers and medical notes were shared, the HSIB found.
The investigation was initiated after a Sage report in May which found that 20% of hospital patients were reporting symptoms of Covid-19 seven days following admission – suggesting that their infection may have been acquired in hospital. In response to the report, NHS England and NHS Improvement confirmed they would publish nosocomial – another term for hospital acquired infections – transmission rates from trusts, the HSIB said.
Read full story
Source: Express and Star, 28 October 2020
 
Clive Flashman

Private children’s unit shut down after CQC safety concerns

A privately run child and adolescent mental health unit has been closed permanently, with its residents moved elsewhere, after concerns were raised about their safety.
The Care Quality Commission (CQC) said it had taken “urgent action to ensure the provider makes immediate and significant improvements” at the Cygnet Hospital in Godden Green, outside Sevenoaks in Kent, after a series of unannounced inspections last month and this month.
The hospital had a CAMHs unit with up to 23 beds – details of which have been removed from the company’s website. However, only a small number of beds were occupied and these patients were either discharged or transferred to other hospitals before the unit closed on Monday.
Last year Cygnet Health Care also launched a 12 bed female psychiatric intensive care unit on the site. Some of these beds have been commissioned by Kent and Medway NHS and Social Care Partnership Trust since early this year, as there are no NHS female PICU sites in the county. This unit remains open, although the CQC said the concerns raised with it related to the safety of both PICU and CAMHs patients.
Karen Bennett-Wilson, the CQC’s head of hospital inspection and lead for mental health in the south, said: “CQC has also worked closely with NHSE/I, Cygnet Healthcare and other local partners who have taken the decision to close the CAMHS unit and move the young people in the service to other care appropriate to their needs."
Read full story (paywalled)
Source: HSJ, 20 October 2020
Sam

Coronavirus delays putting patients’ lives at risk, warn ambulance chiefs

Ambulance chiefs have warned coronavirus precautions in hospital emergency departments are putting patients’ lives at risk because of long delays before patients are being treated.
West Midlands Ambulance Service has written a formal warning to three hospitals in the region over the delays to handing over patients from ambulance to hospital staff.
In one case, a patient was left waiting with ambulance crews for up to three and a half hours.
According to the letter, obtained by the Health Service Journal, the delays are being caused because of tougher infection control measures with ambulance bosses warning the situation is “dangerous”.
Director of nursing Mark Docherty said the delays meant ambulances could not be sent to “life threatening emergencies”, and warned: “Lives will be put at risk and patients will come to harm as a result”.
He added: “I alerted you to a serious concern about patients being kept on ambulances outside your hospital. Of great concern is the fact that a hospital risk assessment identifies this process as a mitigation to reduce risk in your hospital…"
Read full story
Source: The Independent, 29 October 2020
Sam
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